Event Notification Report for July 02, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/01/2009 - 07/02/2009
Hospital
Event Number: 45184
Rep Org: GAMMA KNIFE CENTER OF THE PACIFIC
Licensee: GAMMA KNIFE CENTER OF THE PACIFIC
Region: 4
City: HONOLULU State: HI
County:
License #: 53-1196602
Agreement: N
Docket:
NRC Notified By: RONALD FRICK
HQ OPS Officer: DONALD NORWOOD
Licensee: GAMMA KNIFE CENTER OF THE PACIFIC
Region: 4
City: HONOLULU State: HI
County:
License #: 53-1196602
Agreement: N
Docket:
NRC Notified By: RONALD FRICK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/03/2009
Notification Time: 18:42 [ET]
Event Date: 07/02/2009
Event Time: 14:00 [HST]
Last Update Date: 07/17/2009
Notification Time: 18:42 [ET]
Event Date: 07/02/2009
Event Time: 14:00 [HST]
Last Update Date: 07/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
GREG PICK (R4DO)
DUNCAN WHITE (FSME)
GREG PICK (R4DO)
DUNCAN WHITE (FSME)
MEDICAL EVENT - GAMMA KNIFE MISADMINISTRATION
A gamma knife treatment was prescribed for a patient being treated for multiple brain metastatic sites using an 8 mm collimator. The prescribed dose was 24 gray. The treatment was prescribed for 7 discrete sites in the brain. After the second discrete site had been treated it was found that an 18 mm collimator was being used to administer the treatment instead of the prescribed 8mm collimator.
After discovery, the collimator was changed to the 8 mm collimator. Treatment to the remaining 5 discrete sites was administered with the 8 mm collimator.
Both the patient and the patient's physician were notified of the use of the wrong collimator. The licensee states that there should be no clinical effects to the patient as a result of this misadministration.
The previous patient had been treated using the 18 mm collimator as the prescribed collimator.
Investigation into this event is continuing and a written report will follow.
In an effort to prevent recurrence, the licensee will send a notice to all authorized users, neurosurgeons and medical physicists that they should each independently check collimator size before each treatment is started.
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
* * * UPDATE AT 1551 ON 7/17/2009 FROM RONALD FRICK TO MARK ABRAMOVITZ * * *
"The use of the 18 mm collimator instead of the 8 mm collimator increased the treatment site dose by 3%. The larger collimator caused the volume of each of the two treatment areas to increase by 2.35 cm3 [cubic centimeters]. This additional tissue received a dose of 24 Gy. If the correct collimator had been used, this tissue would have received a dose of approximately 4.3 Gy."
Both the physician and patient have been notified by the licensee.
Notified the R4DO (Gaddy) and FSME (Reis).
A gamma knife treatment was prescribed for a patient being treated for multiple brain metastatic sites using an 8 mm collimator. The prescribed dose was 24 gray. The treatment was prescribed for 7 discrete sites in the brain. After the second discrete site had been treated it was found that an 18 mm collimator was being used to administer the treatment instead of the prescribed 8mm collimator.
After discovery, the collimator was changed to the 8 mm collimator. Treatment to the remaining 5 discrete sites was administered with the 8 mm collimator.
Both the patient and the patient's physician were notified of the use of the wrong collimator. The licensee states that there should be no clinical effects to the patient as a result of this misadministration.
The previous patient had been treated using the 18 mm collimator as the prescribed collimator.
Investigation into this event is continuing and a written report will follow.
In an effort to prevent recurrence, the licensee will send a notice to all authorized users, neurosurgeons and medical physicists that they should each independently check collimator size before each treatment is started.
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
* * * UPDATE AT 1551 ON 7/17/2009 FROM RONALD FRICK TO MARK ABRAMOVITZ * * *
"The use of the 18 mm collimator instead of the 8 mm collimator increased the treatment site dose by 3%. The larger collimator caused the volume of each of the two treatment areas to increase by 2.35 cm3 [cubic centimeters]. This additional tissue received a dose of 24 Gy. If the correct collimator had been used, this tissue would have received a dose of approximately 4.3 Gy."
Both the physician and patient have been notified by the licensee.
Notified the R4DO (Gaddy) and FSME (Reis).
Power Reactor
Event Number: 45181
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: CHRIS DUNN
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: CHRIS DUNN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/02/2009
Notification Time: 18:40 [ET]
Event Date: 07/02/2009
Event Time: 14:15 [CDT]
Last Update Date: 07/02/2009
Notification Time: 18:40 [ET]
Event Date: 07/02/2009
Event Time: 14:15 [CDT]
Last Update Date: 07/02/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MONTE PHILLIPS (R3DO)
MONTE PHILLIPS (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 97 | Power Operation | 97 | Power Operation |
HPCS INOPERABLE DUE TO LOGIC CARD FAILURE
"On July 2, 2009, at 0100 hours (CDT), the Main Control Room received an alarm associated with a failure of the Nuclear System Protection System (NSPS) Self Test System (STS). The indicated failure was on a High Pressure Core Spray (HPCS) system logic card. The card was removed and testing of the card, completed at 1415 hours, determined that the failure was on a circuit that would have prevented the automatic initiation capability of HPCS. Since HPCS is an emergency core cooling system and is a single train safety system, this is reportable under 50.72 (b)(3)(v)(D). It is unknown at this time what caused the failure and plans are in progress to repair or replace the card."
The logic card is being sent out for repairs. The HPCS system will remain inoperable until the card is repaired and replaced. There is no estimate at this time as to when the card will be replaced.
The licensee will notify the NRC Resident Inspector.
"On July 2, 2009, at 0100 hours (CDT), the Main Control Room received an alarm associated with a failure of the Nuclear System Protection System (NSPS) Self Test System (STS). The indicated failure was on a High Pressure Core Spray (HPCS) system logic card. The card was removed and testing of the card, completed at 1415 hours, determined that the failure was on a circuit that would have prevented the automatic initiation capability of HPCS. Since HPCS is an emergency core cooling system and is a single train safety system, this is reportable under 50.72 (b)(3)(v)(D). It is unknown at this time what caused the failure and plans are in progress to repair or replace the card."
The logic card is being sent out for repairs. The HPCS system will remain inoperable until the card is repaired and replaced. There is no estimate at this time as to when the card will be replaced.
The licensee will notify the NRC Resident Inspector.